Three consecutive waves of COVID-19 have evidently expressed an insufficient rural health infrastructure In India three consecutive waves of COVID-19 have exposed the seriously compromised state of rural health infrastructure. Interestingly, non-government organizations, enterprises and charities contributed to the dire situation by way of providing personal protective equipment, medical supplies, appliances, rapid testing kits, including monetary aid. Their participation did provide some respite to the struggling rural healthcare setups in confronting the SARS Cov-2 onslaught, but it pointed towards the need for improved strategic policies to build up the rural healthcare systems to face future unforeseen emergencies.
Rural children in general and, girl child in particular due to prevalent gender discrimination, tend to face worst health outcomes.
It is well-known that in India there exist substantial differences between the urban and rural areas, with poverty affecting lives of people starting from early childhood and increasing as one grows older. Living conditions aside, rural areas also suffer from the lack of social sector services in general. Rural children in general and, girl child in particular due to prevalent gender discrimination, tend to face worst health outcomes. The health disparities between rural and urban children, as well as interstate disparities in health status go hand-in-hand to projecting concerning scenarios for the country. Again, the rural and tribal areas have fewer movement and connectivity options than urban areas. The settlements are dispersed more than urban areas. This necessitates evolving location-specific healthcare service delivery systems for rural areas.
The first pandemic wave in the country affected health and social welfare aspects of women and children, belonging to poorer section of society, adversely. Many pregnant women, without access to proper medical care during childbirth, lost their lives; while some gave birth to underweight and stunted children. These children obviously got subjected to life-long health problems. As observed, in ordinary times, the Indian healthcare systems, more so rural health facilities, face operational challenges, and the challenges observably grew manifold during the pandemic causing catastrophic effects on socio-economic spheres.
The rural healthcare system in rural India, primarily developed on the suggestions of Bhore Committee Report, guided Government of India in adopting population-based norms for establishing the three-tier public health care facilities, as Sub-Centre (SC), Primary Health Centre (PHC), and Community Health Centre (CHC). The current status, of these rural health facilities, as obtained from latest Ministry of Health & Family Welfare statistical data upload in their website, indicate shortfall at the three-tier set up as, 18% at the SC level, that consist of 158417 SCs, 22% at the PHC level that consist of 25743 PHCs and 30% at the CHC level that total 5624 CHCs. According to the National Health Profile 2021, in government hospitals one allopathic doctor is available to cater to 11,082 people, one bed per 1,844 people is the current allocation, and one state-run hospital available for every 55,591 people.
In spite of the elevation in rural health facilities over the years, the manpower availability is notably underneath the wanted tiers, as per World Health Organization suggested levels.
In spite of the elevation in rural health facilities over the years, the manpower availability is notably underneath the wanted tiers, as per World Health Organization suggested levels. Of the sanctioned posts, at the SC level 14 per cent posts of Health Workers (Female)/ ANM, and 37 per cent of Health Workers (Male) were vacant, as Government Rural Health Statistics (RHS)2019-20 indicated. The RHS also stated that the number and post-wise shortage in rural health set up as, 1,704 posts of doctors in PHCs across the rural areas, as well as 5,772 posts of nursing staff, 5,066 positions in female health workers, 6,240 posts of pharmacists, and 12,098 posts of laboratory technicians. The report further added that- of the total 155404 Sub Centre across the country, only 5383 SCs was functioning as per IPHS norms, only 8514 PHCs were functioning on 24×7 basis out of existing 24918 PHCs, and just 4957 CHCs, of the sanctioned 20732 CHCs, were currently functioning in rural areas. An International Journal paper published in December 2020 found that rural India has 3.2 government hospital beds per 10,000 people and that some big states such as, Uttar Pradesh with 2.5 with beds, Rajasthan 2.4 with beds, Jharkhand 2.3 with beds, Maharashtra with 2.0 beds and Bihar with 0.6 beds respectively, stood below the national average. Evidently, the rural healthcare set-up does not provide assuring state of affairs, currently. Besides, there is among the states, dissimilarity as far as access to medical care, appropriation of public health expenditure as well as achieving health outcomes. Obvious therefore that even without the pandemic or unforeseen emergencies, the rural health infrastructure is always stressed, while historically having less access to health services as the figure below will indicate.
The rural public health service management, especially in preventing, controlling or eliminating major communicable diseases, such as Tuberculosis, Malaria, and in reducing the risk of deaths in maternal and perinatal diseases has remained a challenge. In India, endemic diseases caused by infection or lack of nutrition still account for over two-thirds of mortality and morbidity. With rural areas lacking access to elementary healthcare, there remain abundant challenges to setting up strong emergency medical services, as well.
Both increases in government spending and private sector initiatives have improved the health infrastructure, but given the rising demographic pressure in India, this increase does not seem to make the desired difference. It is the extension of life expectancy that has a direct impact on many households. The rising healthcare cost exacerbates the problem for lower- and middle-class households, as well. The suggestive way forward, at this juncture, at empowering rural healthcare systems and building healthy rural communities, can be as follows-
Maximize the implementation of Health and Wellness at the Sub Centres and Primary Health Centres levels–
The health and wellness concept under Ayushman Bharat was an excellent start, as the same advocated a more comprehensive, well-equipped, and well-staffed model of primary healthcare in government sub-centres and primary health centers. Updating them in rural areas will undoubtedly enable in achieving the degree of readiness required in rural India in the event of a pandemic or other unforeseen emergency.
Extended public-private partnerships (PPP) to support healthcare inclusion-
PPP partnerships evidently have potential to revolutionize the rural healthcare system in India, while simultaneously ensuring a long-term viable solution. As the country’s population is growing, government efforts will not be enough to strengthen the healthcare system. PPP can assist in overcoming monetary, specialized, pedagogy, and human capital constraints. Private players can also ensure that Government policies at improving rural healthcare infrastructure are implemented appropriately. Continuing partnerships will improve access to healthcare, especially in the inaccessible rural areas, because individual actors’ extensive expertise, experience and financial resources may aid in the development of novel solutions.
Organise a supervisory committee on the ground–
a local supervision committee formation needed for developing a centrepiece masterplan for improving access to better healthcare and overseeing the implementation of rural healthcare projects. Though the majority of rural healthcare programs often get off to a terrific start, the outcomes are not always as anticipated. To revive rural healthcare service systems, through efficient monitoring of rural healthcare strengthening operations, the local supervisory committee is required.
Doctors working in rural areas encounter several problems when it comes to accessing training opportunities due to their location.
Continuous competency development and mentoring-
Another key concern in rural regions is skill development and mentoring. The CHCs, which acts as a referral of PHCs in rural areas, currently have a 76.1 percent shortage of specialists, as the Ministry of Health and Family Welfare recent report indicated. Doctors working in rural areas encounter several problems when it comes to accessing training opportunities due to their location. In that scenario deployed Doctors can benefit from skill development courses, and ongoing learning programs to assist address the dearth of trained doctors in rural areas. A focused mentoring program, including online or offline sessions, skill upgradation and exchange programs could be extremely helpful in this situation.
Coherent machine upgrade and paramedic training-
Essential amenities, such as most up-to-date medical equipment and skilled medical personnel to operate them, are lacking in rural areas. While medical equipment can still be upgraded on a regular basis, training courses for nurses and paramedical workers on how to handle, operate and manage these machines are also necessary. As new technologies become available, the requirement for training becomes more pronounced and required to be recognized.
In summing up, it needs to be pointed out that it is difficult to overhaul the country’s rural healthcare system within a short timeline, and that a piecemeal approach to improving rural healthcare facilities will be futile. But, with the ongoing dedication and regular efforts can a sturdy rural healthcare system be developed. Implementing the procedures outlined above will have positive benefits in the long run and will contribute to the development of a robust rural health care management system. Beyond COVID, the central objective should be to devise preparedness strategies for unforeseen emergencies, rather than focusing simply on short-term fixes that will return the system to its previous state once external help is withdrawn.
Composed by: “Dr. Gautam Kr Ghosh, is Ph.D in sociology with PG diploma in Reproductive and Child Health Management, and is research scientist at ICMR NICED, Kolkata, India.”
Composed by: “Aprita De, holds Masters in Public Health degree, and is working as Junior Consultant, NHSRC, Ministry of Health and Family Welfare, New Delhi.”